David R. Custin~1~~~ ~~IN ~-
l~ ~ ~~,,~
`; ~-. ~ 1 .
201111^ ~1~ 19 P1~ 3= 48
City of Miami Beach Office of the City Clerl~• !-~ •y~ , L ~; i{,' ~ C) ~_ ` I ~ i=~
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed ~ retained, whether paid or not, W a principal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or eleasion of any commissioner; any actmn, decis~n, recommeruialion of the City Manager or any dty board or
committee: Ot any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on such
adior-, deasion or recommendation that foreseeabty will be heard or reviewed by the city commission, or a city board or committee. The term
Specifx~liy includes the principal as weU as any employee engaged in lobbying activities, The term °t.obbyists" has sp~eciRc exclusions. Please
refer m ordinance 2004Y-S5/. /''
~ Lr S~r/I i /9 v, `~
rvAnntvrwtstsrl5r: (Last) r (First) (M.!)
,,, ~~ ~u' ~ ,~ ~-/`~S r- ®r ~c _ 6401 SW 113 PL, Miami, FL 33173-1083
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-412-3772 305-412-3773
.TELEPHONE NUMBER: FAX NUMBER: EMAIL:
1. LOBBYIST RETAINED BY:
Choice Environmental Services, Inc.
NAM!ME OF PRINCIPAUCLIENT: a /~ ,[~ / j'~~f / /
~ko,c~ ~/!/dr~~7~G~ ~ ( l ~ / C~~fn ~-r2`~ /~l'~~("r- L~iK~~l._-
BUSlZES~NAGE % ~ADDR~S~ ~~ (Number and St eet) (City) (State) (Zip Codej
ll ----
FAX NUMBER: (Optional) EMAIL:
Fitt out this section if principal is a Corporation, Partrrership or Trust [~seyction 2-482 (c))
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: //~/e ~ ,Gj~ //P~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 531, OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: /_' ~~ ,!~`~ //~
Ii.SPEJCI/F)C LOBBY ISS/UE:
to be lobbied
iii. CITY AGENCIES/INDOVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-482(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a](4) include a statement of arty contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to tae lobbied.)
A Pull Name of Individual Title 8 An Financial, Familial or Professional Relationshi
City Manager & administrative staff None
Mayor and City Commission Comm Wolfson: design & printing; direct mail; prof. services
Comm F_xposito: design & printing; diced mail; prof. services
~-
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~J ®fl ~ ~~~~ `
B) PRINCIPAL'S
(Required).
<<Z (~~dl~,P ~ 0~T
2v~.2 5 S ~t o /t
P~1~
The follawiing information must be answered:
1) Pursuant to Miami Beach City Code Section 21188 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
/ Yes No: Are you lobbvinq on a present or pending bid for goods, equipment or services. or on a
present or pending award for goods. equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
I Les I / INo: Are you lobbvinq on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change to the City's Future Land Use
M9D?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
°lobbyist" as set forth in Section 2-481 above) who only appears as a representative of anot-for-profit
corporation or entity without specal compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not tae required to pay any registration fees.
n Yes n No• Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement
V. SIGNATURE UNDER OATH:
1 do solemnly swear that
provisions contained in
Signature of Lobbyist:
Signature of PrincipaUClient:`
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Swom_~~ubscribed b fore me
This day ~p~$' ~O~C7
Signature rida
Notarizati of Lobbyist's signature
TO BE COMPLETED 8Y CITY
Annual Registratlon fee: [ ]Yes [ ] No Amount Paid S 1
Lobbyist Registration Form received and verified by: -_,~
F:\CIER\MATL\Formi ,igbby~-: ~~y.:°-: ~~:,.; cf~.~....ar,r
and that I have read or am familiar with the
81Reporting requirements.
PRINCIPAL IDENTIFICATION:
ProducedlD_~~3j-)fir;-6c/' ~UL'~
Form of Identifrcation
~. ;.
.. ~~ ,i,,,,,,• IgAgEL SATGIEII =r
Personally known (Princi ~ MY COttAMISSIONNDD879891 E
EXPIRES: April 13, 2013
~~.Rtt4'fi` Bc°dedThraNMa~YPuWkUnde~ers
State of Florida, County of Miami-Dade
Swom nd subscribed 4efore me 2O~p
This day of ~ , 2898-
Signatu a of Public Notary -State of Florida
Notarization of Principal's signature
q ~~' 4~~ Date Paid
Revised 03/27/2008
i
lily aF Miami 8eoth, 1700 Convention Center Dr'rve, Minmi Beach, Florida 33139, www.miomibeachfl.gov.
CITY CLERK OfFice CityClericC~-miomibeachfl.gov
Tel: 305.673.741 i ,Fax: 305.673.7254
LOBBYIST NAME: / ~ _ ______ _ ___ _ S" I _~
I understand that no later than Ocbber 1 s# of eoch ,xeas, I must file the following
.forms, pursuant to Section 2 485 of the Miomi Beach City Code, with the City Clerk's
Office for afl active lobbying issues.
1 j Lobbyist Expenditure Form
2j Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-0ade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, 1 om required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
Signature: Date:
R.~visad 02/04r2Qi16